Function #1: Define the scope of work.

• Were the purpose and scope of the work to be performed clearly defined so that workers could identify any unanticipated conditions and actions that would be outside the authorized work scope?

• Were expectations regarding the removal or control of hazards clearly defined and communicated to the workers?

• Were the required safety support activities identified?

• Were roles, responsibilities, and authorities for the work activity defined and executed appropriately?

• Were the worker qualifications required to safely perform the work identified?

• Were the design, operation, and configuration of equipment known and considered in work planning?

• Were the characteristics of the work environment known and considered in work planning?

Function #2: Identify and analyze the hazards.

• Were the type and magnitude of all possible hazards clearly understood?

• Was the accident potential analyzed?

• Were the consequences of potential accidents described and understood by line management, supervisors, and workers?

• Did the workers provide input to the hazard analysis?

• Did the workers receive any feedback regarding their input?

• Were the standards and requirements associated with the hazards identified?

Function #3: Develop and implement hazard controls.

• Were required physical and engineering hazard controls evaluated for likely effectiveness under the expected work conditions?

• Were the required administrative controls, such as technical procedures and safety support personnel, in place?

• Were the workers qualified and given hazard- or activity-specific training?

• Was a proper review, approval, and configuration control process in place?

Function #4: Perform work within controls.

• Was the readiness to perform the work checked and confirmed prior to starting work?

• Was appropriate authorization received to start work?

• Was the work performed as planned (i.e., by the intended workers using the pre-approved procedures with the required level of supervision and safety support present with effective hazard controls in place)?

• Were the workers empowered to stop work if unanticipated or unsafe conditions arose?

Function #5: Provide feedback and continuous improvement.

• Was there a system to collect and use feedback from workers on workplace hazards?

• Were workers aware of any hazards affecting the work activity that were not addressed in planning for it?

• Was management made aware of the hazard(s) identified by the workers?

• Were there any lessons learned locally, from audit or evaluation results or from external operating experience, that applied to the work activity but were not addressed in planning for it?

Guiding Principle #1: Line management is directly responsible for the protection of the public, workers, and the environment.

• Did DOE assure and contractor line management establish documented safety policies and goals?

• Was ISM fully implemented down to the activity level at the time of the accident?

• Was DOE line management proactive in assuring timely implementation of ISM by line organizations, contractors, subcontractors, and workers?

• Were ES&H performance expectations for DOE and contractor organizations clearly communicated and understood?

• Did line managers elicit and empower active participation by workers in safety management?

Guiding Principle #2: Clear lines of authority and responsibility for ensuring safety shall be established and maintained at all organizational levels within the Department and its contractors.

• Did line management define and maintain clearly delineated roles and responsibilities for ES&H to effectively integrate safety into sitewide operations?

• Was a process established to ensure that safety responsibilities were assigned to each person (employees, subcontractors, temporary employees, visiting researchers, vendor representatives, lessees, etc.) performing work?

• Did line management establish communication systems to inform the organization, other facilities, and the public of potential ES&H impacts of specific work processes?

• Were managers and workers at all levels aware of their specific responsibilities and accountability for ensuring safe facility operations and work practices?

• Were individuals held accountable for safety performance through performance objectives, appraisal systems, and visible and meaningful consequences?

• Did DOE line management and oversight hold contractors and subcontractors accountable for ES&H through appropriate contractual and appraisal mechanisms?

Guiding Principle #3: Personnel shall possess the experience, knowledge, skills, and abilities that are necessary to discharge their responsibilities.

• Did line managers demonstrate a high degree of technical competence and a good understanding of programs and facilities?

• Did line management have a documented process for assuring that DOE personnel, contractors, and subcontractors are adequately trained and qualified on job tasks, hazards, risks, and Departmental and contractor policies and requirements?

• Were mechanisms in place to assure that only qualified and competent personnel were assigned to specific work activities, commensurate with the associated hazards?

• Were mechanisms in place to assure understanding, awareness, and competence in response to significant changes in procedures, hazards, system design, facility mission, or life cycle status?

• Did line management establish and implement processes to ensure that ES&H training programs effectively measure and improve performance and identify training needs?

• Was a process established to ensure that (1) training program elements are kept current and relevant to program needs, and (2) job proficiency is maintained?

Guiding Principle #4: Resources shall be effectively allocated to address safety, programmatic, and operational considerations. Protecting the public, the workers, and the environment shall be a priority whenever activities are planned and performed.

• Did line management demonstrate a commitment to ensuring that ES&H programs had sufficient resources and priority within the line organization?

• Did line management clearly establish that integrated safety management will be applied to all types of work and address all types of hazards?

• Did line management institute a safety management system that provided for integration of ES&H management processes, procedures, and/or programs into site, facility, and work activities in accordance with the Department of Energy Acquisition Regulation (DEAR) ES&H clause (48 CFR 970.5204-2)?

• Were prioritization processes effective in balancing and reasonably limiting the negative impact of resource reductions and unanticipated events on ES&H funding?

Guiding Principle #5: Before work is performed, the associated hazards shall be evaluated and an agreed-upon set of safety standards shall be established that, if properly implemented, will provide adequate assurance that the public, the workers, and the environment are protected from adverse consequences.

• Was there a process for managing requirements, including the translation of standards and requirements into policies, programs, and procedures, and the development of processes to tailor requirements to specific work activities?

• Were requirements established commensurate with the hazards, vulnerabilities, and risks encountered in the current life cycle stage of the site and/or facility?

• Were policies and procedures, consistent with current DOE policy, formally established and approved by appropriate authorities?

• Did communication systems assure that managers and staff were cognizant of all standards and requirements applicable to their positions, work, and associated hazards?

Guiding Principle #6: Administrative and engineering controls to prevent and mitigate hazards shall be tailored to the work performed and associated hazards.

• Were the hazards associated with the work activity identified, analyzed, and categorized so that appropriate administrative and engineering controls could be put in place to prevent or mitigate the hazards?

• Were hazard controls established for all stages of work to be performed (e.g., normal operations, surveillance, maintenance, facility modifications, decontamination, and decommissioning)?

• Were hazard controls established that were adequately protective and tailored to the type and magnitude of the work and hazards and related factors that impact the work environment?

• Were processes established for ensuring that DOE contractors and subcontractors test, implement, manage, maintain, and revise controls as circumstances change?

• Were personnel qualified and knowledgeable of their responsibilities as they relate to work controls and work performance for each activity?

Guiding Principle #7: The conditions and requirements to be satisfied for operations to be initiated and conducted shall be clearly established and agreed upon.

• Were processes in place to assure the availability of safety systems and equipment necessary to respond to hazards, vulnerabilities, and risks present in the work environment?

• Did DOE and contractor line management establish and agree upon conditions and requirements that must be satisfied for operations to be initiated?

• Was a management process established to confirm that the scope and authorization documentation is adequately defined and directly corresponds to the scope and complexity of the operations being authorized?

• Was a change control process established to assess, approve, and reauthorize any changes to operations scope ongoing at the time of the accident?